Basic Information
| Provider Information | |||||||||
| NPI: | 1568990315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | DEVADAH | ||||||||
| MiddleName: | LA JEUNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
| FaxNumber: | 3525368841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
| FaxNumber: | 3525368841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 9218029 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | ARNP9218029 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LA2200X | APRN9218029 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 022286700 | 05 | FL | MEDICAID |